HEALTHCARE EXPLORATION PROGRAM,

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1 Thank you for your interest in the Healthcare Exploration Program. Please complete the following application form and short essays, and provide all other requested documents. Incomplete applications will not be considered. All applications, in their completed form, are due by 4:00 p.m. on February 16 at 124 Siringo Road. Should a weather emergency require the closing of our office, the application will be due the next business day the office is open. Postmarks are not considered. Your Application Packet must include: 1. Completed application signed by student and parent/guardian 2. Media consent form signed by student and parent/guardian 3. Personal recommendation form in an envelope signed across the seal by the recommender 4. Teacher recommendation form in an envelope signed across the seal by the teacher 5. Official copy of transcripts and attendance/tardy records from the past 2 academic years through end of second quarter academic year 6. Typed responses to short essay questions (12 point font, 1 inch margins) 7. Photocopy of student ID clearly showing photo Failure to include any of the application materials, or leaving blanks in the application form, will result in the disqualification of your application. The receptionist at the education building will not be able to review the application when it is delivered. All application materials must be postmarked or delivered in person by 4:00 p.m. on February 16, Faxed or ed applications will not be accepted. Incomplete and late applications will not be considered. Applicants who are selected to be interviewed will be notified by March 7 via . Mail or hand-deliver to: CHRISTUS St. Vincent Education Building 124 Siringo Road Santa Fe, NM or Personal Information HEALTHCARE EXPLORATION PROGRAM, JUNE 1-27, 2015, 9:00-3:00

2 Qualifications for participation in the program: 1. The Healthcare Exploration Program (HEP) Levels I and II are only for current high school students. Therefore, we cannot consider applications for Level I from Juniors or Seniors in high school as they will no longer be high school students in the Summer of However, if a student is a high school Junior they are welcome to apply for the few openings in Level II. Those interested Juniors need to contact Louise Yakey at louise.yakey@stvin.org for that application. 2. All successful applicants must agree to a drug/alcohol test before they begin the program. Should the successful applicant have a drug test that is positive for any drug for which they do not have a current prescription, will be eliminated from the program. 3. Only applicants that will be 15 years old by June 1 will be considered for the program. 4. Only applicants who attend a school with district offices in Santa Fe County will be considered. 5. Only applicants who have received all childhood immunizations will be considered. There is no conscientious objector allowance. Immunizations records will be submitted to the Employee Health nurse when successful applicants complete the drug/alcohol screening. 6. Applicants who are finalists must be interviewed by the selection committee. If a student is unable to attend an interview, they will not be considered for the program. Those students selected for an interview will notified on or about March 7. Interviews are the week of March 17 and The Summer 2015 program will be held Monday-Friday, June 1-27, from 9:00 to 3:00 daily. Only students who can attend the entire program will be considered. 8. Applicants must have a valid address that they check daily as all communication is via . Applicants who do not respond to correspondence will be eliminated from consideration. 9. Overall grade point average should be a B (3.0) at the time of application and at the end of the current academic year. 10. Those applicants with excessive tardies or unexplained absences will not be considered. 11. Only one personal and one teacher recommendation will be considered. Recommendation letters received that are not sealed in an envelope and signed across the seal by the recommender will result in the application being eliminated from consideration. Recommendation letters must be included in the application packet and are not to arrive via or under separate cover from the application packet. Note: All applications are blinded for student s and their parents identities, address, gender, and school attended before the applications are distributed to the members of the selection committee and that information is not used in deciding who is chosen to be interviewed. Should an applicant wish to have an employee of CHRISTUS St. Vincent Regional Medical Center serve as a reference, that employee should be asked to complete the personal reference form. Telephone calls, s, and other personal contact of the selection committee is not allowed.

3 Application Cover Page Name of Birth Mailing Address City, State, Zip Code Cell Phone_ Home Phone_ I currently live with: Family Background School year completed by June 2015 Freshman Sophomore Parent/guardian #1 Cell or home phone Parent/guardian #2 Interests and Activities Cell or home phone

4 Please list your top 3 activities athletic, artistic, community, musical, etc. in the order of their importance to you: ACTIVITY NUMBER OF YEARS POSITIONS, AWARDS OR LEVELS ACHIEVED Choose one activity and briefly discuss how your participation has contributed to your growth. List 3 places where you have been employed and/or done volunteer work, your responsibilities, the duration, and contact information for each work or volunteer experience.elf Assessment Work/Volunteer Experience Duration Responsibilities Contact person and phone number Choose one work or volunteer experience and briefly discuss how your participation has contributed to your growth.

5 Do you speak another language in addition to English? Yes No Please complete the following sentences: My three greatest strengths are Three areas of improvement for me would be Three areas of the healthcare field that interest me the most include Have you ever been convicted of a crime? A conviction will not bar you from consideration in this program. Yes No If yes, explain: Is there any circumstance which might limit your participation during the HEP program? Yes No If yes, explain: I certify that all information given is true to the best of my knowledge and that the short essay questions are not plagiarized nor written by someone else on my behalf (Assistance with composition and proofreading is acceptable.) I understand that, if selected, to participate in HEP, I will be required to submit to an alcohol/drug test. Student Signature I understand that if selected my child/ward will participate in observation-only clinical rotations in real patient care settings, receive education regarding medical subjects and clinical situations that may be graphic, and receive information regarding health-related issues and the circumstances contributing to those issues. I understand that if selected to participate in HEP, my child/ward will be required to submit to an alcohol/drug test. I do hereby consent to my child s/ward s participation in the CHRISTUS St. Vincent Regional Medical Center Healthcare Exploration Program. Parent/Guardian Signature

6 Short Essays: Write one fully developed paragraph response to each of the following questions or statements below. Be mindful to write with attention to clear, specific content as well as grammar. Responses should be typed with 12-point font, 1-inch margins. Although you are most welcome to get assistance with organizing your thoughts and proofreading, the final work must be your own and you should be prepared to discuss your answers should you be chosen for an interview. Handwritten essays will result in disqualification of the application. 1. Why should you be chosen for this program? 2. What traits do you admire in a person and why? 3. Explain an ethical dilemma you have had experience with and what your response to the dilemma was. 4. What do you see as the biggest challenge in healthcare today? Explain your answer. NA L E S

7 Media Consent Form Name of Birth Mailing Address City, State, Zip Code Cell Phone_ Home Phone For publicity, promotional, advertising, printed, or educational material I hereby consent to being photographed, filmed, and/or interviewed by St. Vincent Hospital Foundation and CHRISTUS St. Vincent Regional Medical Center. I hereby give my permission that these photographs, films, and information may be used as follows: IN THE EVENT YOU ARE SELECTED TO PARTICIPATE I understand that photographs, film/videotape, and/or interviews are intended for public viewing and I consent to the use and release of my identity. Student Signature Parent/Guardian Signature For radio, television and/or print media Student Signature Parent/Guardian Signature

8 Teacher Recommendation The Healthcare Exploration Program (HEP) at CHRISTUS St. Vincent Regional Medical Center (CSVRMC) is an extraordinary opportunity for a small, highly motivated, diverse group of Santa Fe County high school students to expand and develop their interests in medicine. In a rigorous, professional environment, HEP students learn hands-on medical skills, attend guest lectures, and observe staff and patient care in over thirty different departments at CSVRMC. Student Teacher, Position, School Class taught/year Phone/ In your letter of recommendation, please discuss what in particular you have observed regarding the character of this student and why he/she might be a strong candidate for this program. If applicable, please describe any reservations you have about the student s ability to participate. PLEASE PLACE YOUR RECOMMENDATION IN A SEALED ENVELOPE WHICH INCLUDES THE RECOMMENDER S SIGNATURE ACROSS THE SEAL. THE STUDENT WILL INCLUDE THIS IN HIS/HER APPLICATION PACKET.

9 Personal Recommendation To be written by any adult who is not a teacher or relative The Healthcare Exploration Program (HEP) at CHRISTUS St. Vincent Regional Medical Center (CSVRMC) is an extraordinary opportunity for a small, highly motivated, diverse group of Santa Fe County high school students to expand and develop their interests in medicine. In a rigorous, professional environment, HEP students learn hands-on medical skills, attend guest lectures, and observe staff and patient care in over thirty different departments at CSVRMC. Student Your name/phone/ Relationship to student/how long? In your letter of recommedation, please discuss what in particular you have observed regarding the character of this student and why he/she is a strong candidate for this program. If applicable, please describe any reservations you have about the student s ability to participate. PLEASE PLACE YOUR RECOMMENDATION IN A SEALED ENVELOPE WHICH INCLUDES THE RECOMMENDER S SIGNATURE ACROSS THE SEAL. THE STUDENT WILL INCLUDE THIS IN HIS/HER APPLICATION PACKET.

10 Transcript Request Form including Attendance/Tardy Records T R A N S C R I P T R E QUE S T F O R M Please sign and give this form to your child s School Registrar. To the Parent/Guardian: I, the parent/guardian of request and authorize the release my child s educational records to Organizational Development, CHRISTUS St. Vincent Regional Medical Center. Student: Grade: School: Parent/Guardian Signature To the School s Registrar: Please submit the following high school records: Official transcript including current year and previous year s grades/courses taken and attendance/tardy records. Registrar s name: School: Registrar Signature PLEASE PLACE THE TRANSCRIPTS IN A SEALED ENVELOPE WHICH INCLUDES THE REGISTAR S SIGNATURE ACROSS THE SEAL. THE STUDENT WILL INCLUDE THIS IN HIS/HER APPLICATION PACKET.